Medications

Question 1

What are pros and cons of Benzodiazepines?

Temazepam

Answer 1

Pros:
Good short term efficacy
Low interaction profile, high Lethal dose
Minor side effects (depending on 1/2 life)
Very short 1/2 life: rebound insomnia
Very long 1/2 life: problems w/ morning functioning, memory

Cons:
Not rec. for long term use
Not curative (gains lost when Tx stopped)
Rebound insomnia (when you come off meds)
Suppresses SWS or REM
Drug dependence? Anxiety and/or pain

Question 2

Non benzo (e.g. zolpidem, zalpelon, zopiclone)
Benzo receptor agonist

Answer 2

Pros:
Good “short” term efficacy
May be used safely up to 6 mos
Low interaction profile
High LD
Few side effects
Doesn’t suppress SWS or REM
Does not result in rebound insomnia

Cons:
Not curative (gains lost when Tx stopped)
Parasominogenesis (pegged to zolpidem,)

Question 3

Melatonin agonists (M1 and M2 receptor agonists)
Ramelteon (Rozerem)

Answer 3

Pros:
“Established” efficacy
May be used safely for extended intervals
Low interaction profile (except fluvaxamine)
High LD
Few side effects (possible exception: gonadotrophic hormones)
Doesn’t suppress SWS or REM
Doesn’t result in rebound insomnia

Cons:
Not curative
Gains are lost when Tx stopped

Question 4

Orexin Antagonists
DORAs
Belsomra, Dayvigo

Answer 4

Pros:
“Established” efficacy
Low interaction profile
High LD
Few side effects
Doesn’t suppress SWS or REM
Doesn’t result in rebound insomnia

Cons:
Not curative (gains lost when Tx stopped)
Parasomnias (in label)- more to do with orexin deficiency and narcolepsy
Weakness or sleep paralysis (in label)
Pregnancy: based on animal data, may cause fetal harm
Narcoleptogenesis

Question 5

Low dose Tricyclics

Doxepin

Answer 5

Pros:
Good short term efficacy (WASO only)
Good durability (3 months)
No appreciable effects on sleep architecture
Minor side effects at hypnotic doses (?)
Data exists for long term administration in MDD
Low abuse potential

Cons:
Not curative (gains lost when Tx stopped)
Interacts w/ other meds?
Possible cardio effects?
Anticholinergic side effects?

Question 6

Antidepressants for insomnia

E.g. elavil, trazodone

Answer 6

Pros:
Good short term efficacy ?
Minor side effects at hypnotic doses?
Data exists for long term administration in MDD
Low abuse potential

Cons:
Interact with other meds?
Possible cardiac toxicity?
Anticholinergic side effects?
PLMs as an iatrogenic effect (more so w/ elavil)
Off label Rx for primary insomnia
Not curative (gains lost when Tx stopped)
Rebound insomnia
Suppresses REM (not so much w/ trazodone)

Question 7

Overall summary of medications for Tx of insomnia

Answer 7

BZRAs have good efficacy and reasonably safe
Melatonin agonists are iffy
Antipsychotics- the jury is out